Clinical Medical Anthropology

Clinical Medical Anthropology is the intersection of applied medical anthropology that coincides with my personal interests due to my degrees in Human Biology and Psychology and my specializations in Bioethics, Humanities, and Society and Health Promotion. This sub-field appeals to me since clinical anthropologists operate as a facet of an interdisciplinary health care team in a hospital, health program, or health agency to improve quality of health care (Pui, 2003). In addition, clinical medical anthropologists are flexible in that the setting in which they work ranges from the developing world to domestic rural and urban locations.

If I were working for a healthcare practitioner, I would explain that hiring a clinical anthropologist is useful in that they contextualize ethnomedical health care beliefs and practices, emphasize experiential aspects of illness in cultural terms, and enhance the cultural sensitivity of physicians, nurses, medical technicians, and hospital administrators. For example, the World Health Organization and UNESCO declared 1996 the Year of Culture and Health, underscoring the paramount role that cultural explanatory models and cultural norms play in international health initiatives (Helman, 2007). In essence, clinical anthropologists can raise awareness about sociocultural barriers to health seeking behavior and compliance, act as advocates for patients of diverse cultural backgrounds, and improve physician-patient communication and satisfaction alike.

For example, in the YouTube video “Medical Anthropology,” it is described how a well-intentioned woman who tried to educate Peruvian villagers about water contamination was unsuccessful due to her failure to recognize the cultural belief that boiling water destroys the spirit of the earth. As Taz mentioned, clinical anthropologists can “act as cultural mediators to develop strategies for individual patients” tailored to cultural values and ideology (Karim, 2012). For example, the significance of employing culturally appropriate terms is demonstrated by Miss Lin, who dropped out of cognitive behavioral psychotherapy due to the providers’ use of technical jargon such as “anxiety disorder” and “depressive disorder” (Kleinman & Benson, 2006). In this case, the Chinese stigmatization of mental illness precluded her pursuit of further medical care; a clinical anthropologist was valuable in this instance since “neurasthenia” carried more culturally-appropriate connotations.

Conversely, clinical anthropologists can also facilitate cultural competence on the part of health care practitioners via “reflexivity…the ability to honestly examine their own cultural ‘baggage’, such as prejudices or particular beliefs, that may interfere with the successful and humane delivery of health care” (Helman, 2007). This mission is central to the US government’s Office of Minority Health (OMH), whose objective is to design culturally targeted health services, ensure informed consent, and reduce cultural health inequities (Helman, 2007). As Kleinman and Benson (2006) purport, suspension of ethnocentrism on the part of the health professional is fundamental since, “The culture of biomedicine is now seen as key to the transmission of stigma, the incorporation and maintenance of racial bias in institutions, and the development of health disparities across minority groups”.

 

References

Helman, Cecil G. (2007). Culture, Health, and Illness (5th ed.). UK: Hodder Arnold.

Karim, Taz. Medical Anthropology. Michigan State University. 10 August 2012.

Kleinman, A. & Benson, P. (October 2006). Anthropology in the Clinic: The Problem of Cultural Competency and How to Fix It. PLOS Medicine, 3(10): 1673-1376.

“Medical Anthropology” –Tribal Jazzman Scholar, Episode #26 [Video File]. August 10, 2012. Retrieved from http://www.youtube.com/watch?v=NjDPwF9uV58

Pui, Jasmine. (September/October 2003). Medical Anthropology. Unique Opportunities: The Physician’s Resource.

 

HIV/AIDS in Malawi

According to AVERT, a humanitarian foundation based in the United Kingdom, AIDS is the leading cause of adult mortality in Malawi, where one in fifteen people have HIV. Social variables that represent greater risk include urban residency, being female, and age between 13 and 24 (AVERT, 2011).  Gender stratification has magnified the epidemic since the subjugation of women translates into sexual abuse, sexual coercion, and inability of women to advocate for condom use. Although the government has discouraged wife inheritance, this cultural practice also manifests as AIDS transmission in some cases. Certain occupations, such as those in the sex industry, policewomen, and male primary school teachers represent disproportionately afflicted populations.

Historically, the reign of Malawi President Banda from 1964 to 1994 resulted in escalating HIV incidence, due to his moral objection to sexual discourse. Hence, social conduct dictated that HIV/AIDS discussion was taboo, derailing preventative measures. Public dissent and international pressure resulted in Banda’s surrendering of power, the inauguration of democratic President Muluzi, and the introduction of a more liberal political climate that enabled AIDS education without political persecution. However, the intolerance fostered by the Banda era had already reaped devastation to Malawi’s socioeconomic infrastructure, culminating in a severe impoverishment and a 2002 famine.

The National AIDS Commission (NAC) was established in 2001 to implement AIDS prevention, testing, and treatment.  These efforts were amplified and supplemented with support services by a multi-sectoral National AIDS Policy put into operation by President Mutharika, elected in 2004.   Moreover, the NGO Malawi AIDS Counseling Resource Organization (MACRO) began providing voluntary counseling and testing (VCT) in 1995. Also, NGOs such as PSI and Banja La Tsogolo and a 2008 UN project have facilitated modest success in promotion of condom use.  In particular, they have used beauty salons to distribute female condoms to circumvent cultural norms whereby it is seen as a traditional male domain. Collaboration of the Malawi government with the Global Fund and civil society organizations such as the World Health Organization, UNAIDS, and The President’s Emergency Plan for AIDS Relief (PEPFAR) has also resulted a dramatic increase in dissemination of antiretroviral drugs.

But, efficacy of campaigns has been limited due to financial shortcoming, in particular due to withdrawal of support by the UK Department for International Development (DFID) and other donors due to suspected political corruption and mismanagement. Additional impediments include deficient human resources, training, and equipment, drug stock-outs, and failure to target health messages to culture or language. Especially problematic is lack of human resources resulting from migration, unsatisfactory education, and loss of health care workers due to AIDS. Although access to rapid screening has increased, only 1% of adults employed this service up until 2003, due to lack of transportation and the cultural stigma of accessing VCT clinics or being diagnosed as HIV-positive, especially for married women (AVERT, 2011).  Furthermore, because homosexuality is illegal, prevalence rates among gay men have not been collected, impeding intervention efforts.  Community leaders have made some progress in changing attitudes toward AIDS, however, as evidenced by Chief Mudwa’s claim: “We have made it policy that whoever discriminates against people living with HIV and AIDS shall be heavily fined or expelled from our kraals (villages)” (AVERT, 2011). In addition, prevention of mother-to-child transmission of HIV (PMTCT) efforts have been hindered by excess demand for tests and inadequate staff, which compromises test quality.

Although deaths due to AIDs have declined in Malawi, numbers of new infection have increased.  This necessitates a strategy where AIDS is combated on multiple fronts in concert with promotion of HIV nutrition, treatment of opportunistic pathogens, and confronting socioeconomic barriers. An anthropologist working in this area is Dr. Anat Rosenthal, who has examined the means by which local and global health organizations affect AIDS in Malawi communities, the sociocultural effects of AIDS-related health policy, and the more general objectives of evaluating and preventing HIV/AIDS outbreaks (Boh, 2011). For example, she conducted participant observation to discern community perception of the Malawi Diffusion and Ideational Change Project (MDICP), whose mission was to elucidate how social networks act in shaping attitudes to family planning and HIV/AIDS (Rosenthal, 2005).  Through ethnographic research, Rosenthal studied the role this survey enacted in day-to-day Malawi lives. In essence, her intention was to uncover the impact of this project and provide recommendations for improving its design, ethics, and the community cooperation (Rosenthal, 2005).

References

Boh, Patricia. (January 27, 2011). Medical anthropologist promotes AIDS awareness in Malawi. The Daily Campus. Retrieved from http://www.smudailycampus.com/news/medical-anthropologist-promotes-aids-awareness-in-malawi-1.1922507#.UCXM2qNSQ-0

HIV & AIDS in Malawi. (2011). Retrieved August 10, 2012 from http://www.avert.org/aids-malawi.htm

Rosenthal, Anat. (September 26, 2005). MDICP-3 Ethnographic Project: Assessing Community Reaction to a Large Scale Survey. Social Network Project Working Papers, 1-18.

ADHD

1) First, Attention Deficit Hyperactivity Disorder has been medicalized in U.S. culture in order to broaden the audience to which drugs such as Ritalin and Adderall can be marketed. Defining ADHD as a permanent condition amplifies profits margins for the pharmaceutical firms such as Ciba-Geigy and other fiscally invested parties. In addition to this economic incentive, the social climate has engendered diagnostic expansion because ADHD enables the medicalization of underperformance and access to legal disability remuneration as well as academic and occupational accommodations. Also, given the ‘pill for every ill’ mentality that the pharmaceutical revolution has produced, symptoms of inattention and distraction are prime candidates for medicalization in the form of ADHD because of “the American public’s decreasing tolerance for mild symptoms and benign problems” and a shift away from psychotherapy in managed care (Conrad, 2000). In the post-Prozac era, the medicalization of ADHD also reflects “the idea that designer drugs might improve the functioning of most anyone” (Conrad, 2000). Furthermore, individual sufferers, self-help and lay advocacy groups themselves motivated the expansion of the ADHD category to adults, since it legitimizes their woes, allows them to embrace a new social identity, and transforms diffuse and ambiguous symptoms into a meaningful illness label. This domain expansion is also understandable in the context of a sociocultural movement to engage individuals more actively in health care delivery, demanding patients be involved agents in the medical decision-making process.

In addition, psychiatric professionals and clinicians also played a hand at medicalizing ADHD, as evidenced by the transformation of DSM categorizations that enabled symptoms to manifest in adulthood. For example, with successive editions, less emphasis was placed on age as a criterion: “‘Frequently calls out in class’…became ‘often blurts out answers to questions before they have been completed” (Conrad, 2000). In effect, definitions were adapted to encompass adult hyperactives, casting a wider net such that more people fell under the rubric of ADHD. Media claims and publications by intellectuals, such as Frank Wolkenberg, also facilitated the medicalization of ADHD (Conrad, 2000). By catapulting into the public spotlight testimony from someone who identified signs of ADHD retrospectively, people could reframe their childhoods to reconcile with a diagnosis of ADHD. Moreover, ADHD was given evolutionary credence when academic Thom Hartmann associated the condition with the transition from nomadic hunting societies to sedentary agricultural societies (Conrad, 2000). By the same token, ADHD was made fashionable and de-stigmatized with confessions by scholars who were afflicted, and speculations that revered figures such as Albert Einstein and Bill Clinton had the disorder (Conrad, 2000).

2) In this advertisement, the company appeals to parents’ ambitions to have a healthy, successful child capable of academic achievement and assimilation into the social milieu. Specifically, the advertising strategy plays on parental fears of their child’s learning disability causing insecurity and self-doubt with regard to scholastic performance (the antagonist) by juxtaposing this with the vision of a happy, secure child seizing the day (the protagonist). Improved concentration and attention is portrayed as a commodity to be gained by investing in Adderall. Cultural valuation of education is demonstrated with the heading, “Soar Confidently into Summer and the New School Year: Try Adderall – It May Make a Difference,” with dramatic words like “soar” capturing the notion of skyrocketing grades resulting from their drug. It also capitalizes on a parent’s social role as the caretaker and provider of resources and opportunity for their child by encouraging the parent to have their child try Adderall in the summer time when parental care is maximal. This can also be interpreted as the company’s customer-oriented stance, as they are considering the most convenient time for the medication to be employed. By the same token, the ad conveys that a parent should be proactive in health management decisions, alluding to notions of patient empowerment. Doctor-patient interactions are addressed by stating that Adderall should only be administered “with close physician supervision,” which also communicates a collaborative rather than a commandeering relationship between practitioner and patient.  As direct-to-consumer advertising, the company presents medical information in a jargon accessible to layman understanding, purports benefits of switching from existing brands (ie. “It May Make a Difference”), and emphasizes Adderall’s unique chemical formula (“the only ADHD product available that contains both dextro and levo amphetamine”).  Side effects are downplayed by using phrases such as “possibility of,” “potential for,” and “rare cases”. Furthermore, attention is diverted away from their specific product by introducing side effects with blanket statements referring to the class of drugs, including, “As with most psychostimulants…” whereas with benefits they called the drug by its brand name. ­­­­

References

Conrad, P. & Potter, D. (2000). From Hyperactive Children to ADHD Adults: Observations of the Expansion of Medical Categories. Social Problems, 47(4): 559-582.

BLTC. (1995). Amphetamines and other Psychostimulants. BLTC Research. 3 August 2012. Retrieved from http://amphetamines.com/adderall/adderallad.html

Medication/Enhancement

1) The “culture of biomedicine” alludes to Western medicine as a microcosm of Western culture, embodying and reinforcing the values, ideology, hierarchy, kinship structures, and power dynamics of Western culture. For example, the arrangement of allopathic medical personnel reflects the classism and gender stratification that typify Western society. As such, biomedicine replicates gender relations and represents a quasi-family in the sense that physicians have historically been a male ‘father’ character while nurses were predominately a female ‘mother’ character’, with the former endowed with more prestige and entitlements. This concept is important since, despite operating on premises of objectivity, empiricism, and universal truth, theory and organizational structure in biomedicine reflects cultural attitudes.

For example, as cited in lecture, anthropologists adopt the view of a hospital as a “miniature city, where each ward is a different suburb with its own administration, bureaucracy, workers, security, and a fluid stream of patient citizens,” demonstrating how biomedicine is a subculture embedded within a larger cultural context (Karim, 2012).  Thus, it also epitomizes socioeconomic aspects of Western culture such as a capitalist, competitive spirit between practitioners and a market-driven fee-for-service paradigm, where a hospital is a for-profit enterprise. Furthermore, the “culture of biomedicine” is aptly named because it exemplifies culture-specific rites of passage. For example, a rite of transition is illustrated by the sequestration of the sick in a hospital, which could be interpreted as a trial of ordeal in the liminal period between illness and health. Furthermore, recitation of the Hippocratic Oath is a component of the rite of incorporation whereby medical students become endowed with the esteem and privilege of a doctor. Moreover, biomedicine is cultural in that health care delivery observes taboos and rituals, including pre-operative hand washing, instrument sterilization, and use of caps, masks, and ‘booties’ in the surgical theater, despite a deficiency in literature supporting that these last practices reduce risk of infection. As Quebbeman notes, these customs “function to define ‘us’ and differentiate and distance ‘us’ from ‘them’”.

2) In my opinion, the medication-enhancement dichotomy separates drugs that can fix, as in eradicating acute illness and reversing chronic, degenerative illness, from drugs that can improve quality of life, such as preemptive treatments that forestall disease development. I think my personal view comes from labels used in the cultural of biomedicine that divide treatments of emergency or ‘medical necessity’ from those that are ‘elective’ or ‘cosmetic’. Originally, this language was likely employed by insurance companies in defining therapies for which reimbursement is possible.

3) I think that the dichotomy of medication-enhancement has emerged due to the pharmaceutical innovations that have essentially enabled the institution of medicine not only to relieve suffering, but to extend life expectancy and healthy years. On the one hand, the germ theory gave rise to vaccinations against biological threats such as polio and smallpox, showcasing the near-miraculous potential of medicine to eliminate infectious disease. Because acute, epidemic disease declined, the medical community shifted efforts to treat non life-threatening conditions and to magnify health and human potential. For example, the inception of Viagra medicalized less-than-perfect sexual performance and represented a life enhancement for those with only occasional erectile dysfunction (Cohen, 2009). Similarly, Ritalin can be a “cognitive enhancer,” augmenting working memory capacity and productivity in healthy subjects (Cohen, 2009). Furthermore, statins are now prescribed to preempt heart attacks, representing a widening of the net where medicines are now designed to treat risk factors (Cohen, 2009).  Such developments have set the stage for the impression that medicine could not only produce ‘quick fix’, magic bullet cures, but also enhance health and longevity, generating a seemingly natural medication-enhancement dichotomy.

References

Cohen, A. (Editor). (2009). Pill Poppers[Documentary]. United Kingdom: BBC Horizon.

Karim, Taz. Medical Anthropology. Michigan State University. 3 August 2012.

Quebbeman, E.J. (1996). Rituals in the Operating Room: Are They Necessary? Infectious Diseases in Clinical Practice, 5(2): S68-S70.

Fibromyalgia

According to the U.S. National Library of Medicine, fibromyalgia causes fatigue, musculoskeletal pain, spasms, and stiffness, numb extremities, and “tender points” sensitive to tactile stimulation and pressure. Other symptoms it causes include insomnia, headaches, anxiety and depression, dry eyes or mouth, impaired proprioception, and cognitive disturbance known as “fibro fog” (familydoctor.org, 2010).  A disease of unknown etiology, fibromyalgia commonly afflicts middle-aged women and is often comorbid with other autoimmune conditions. As mentioned by the author of the fibromyalgia blog, American popular culture portrayals and in particular the image propagated by the pharmaceutical industry in media advertisements, can influence the illness experience of someone with fibromyalgia. By distilling fibromyalgia down to an overgeneralization such as, “Fibromyalgia is explained as widespread pain that doesn’t go away,” this minimizes the debilitating nature of the disorder and neglects the multitude of symptoms that plague sufferers, such as what toydiva65 describes as “morning wood,” “the potty dance,” “the faux heart attack,” “sleeping beauty,” “the carnival dizzies,” and “tummy troubles,” (toydiva65, 2010). Moreover, claims of commercials to provide “significant relief” perpetuate the notion that fibromyalgia is temporary and fixable, which gives the public the impression that a magic bullet cure is available, diminishing the permanent disablement of the chronic illness experience (Lyrica Ad, 2011).

Moreover, these oversimplifications perpetuated by the biomedical community downplay the severity of fibromyalgia, making it harder for patients to mobilize social support and adopt aspects of the sick role such as abdicating regular responsibilities. In addition, because the pathophysiology of fibromyalgia is idiopathic and because symptoms are subjective, facets of this syndrome are not amenable to clinical, biomedical measures and are subject to interpretation by the physician. As lecture noted, the “effective communication of pain or suffering is essential to legitimizing the sick role” (Karim, 2012).  Hence, failure of the practitioner to acknowledge the condition due to insufficient relaying of the illness narrative means the illness will not be identified and therefore not validated by the larger community. In turn, this affects potential for recovery, as patient and doctor must reach a consensus about the illness in order for therapeutic course to be pursued. Also, because biomedicine represents authoritative knowledge, failure of the practitioner to legitimize fibromyalgia means the patients’ symptoms will be dismissed by friends and family (perhaps to the point of the patient being called a hypochondriac or malinger), remedies will not be employed, and poor prognosis will ensue.

If the doctor does not authenticate the patient’s condition or have faith in medications to treat it, this doubt will be translated to the patient. Therefore, the nocebo effect, or the negative effect of beliefs and expectations on health, will come into play and negate the therapeutic action of any drugs. The connection between belief and healing is that the effect elicited by a treatment is congruent with a patient’s belief in the efficacy of that treatment.  For instance, in “Placebo: Cracking the Code,” when Benedetti gives Andre an inert placebo but describes it as a painkiller, Andre reports less pain upon administration of an electric shock due to his expectation of its analgesic effects. Similarly, in my own experience, my belief in the potency of a medicine allows it to provide me greater relief; for example, I have noticed that I prefer the name brand Advil over the generic Ibuprofen despite identical active ingredients. The micro-context or rituals associated with a treatment also impinge upon its success via expectancy effects. This is illustrated in the case of Jean Pierre Bely, who was cured of multiple sclerosis upon his pilgrimage to St. Bernadette, which is a testament to the mind-body connection and power of belief.

The placebo effect may be mediated by the power of suggestion, symbolic healing, the meaning of drugs ingested, or the attitude conveyed by healer. The last case is demonstrated by Dr. Albert Mason and his patient with congenital ichthyosiform erythroderma. The physician’s confidence that hypnosis would eliminate warts was communicated to the patient, heightening his suggestibility, and generating a cure. Most likely, the physiological mechanism of the placebo effect is activation of the patient’s endogenous reservoir of healing substances, such as enkephalins.

References

Familydoctor.org editorial staff. (February 2010). Fibromyalgia. MedlinePlus. Retrieved from http://www.nlm.nih.gov/medlineplus/fibromyalgia.html

Karim, T. (July 2012).Week 4: Lecture 1 – Experiencing Illness. Retrieved from http://anthropology.msu.edu/anp204-us12/schedule/week-4/

Lyrica Ad [Video file]. (October 17, 2011). Retrieved from http://www.youtube.com/watch?v=HSqRBMjEWvY

Placebo: Cracking the Code [Video file]. (November 5, 2011). Retrieved from http://www.youtube.com/watch?v=QvbQnMvhQFw

Toydiva65. (March 16, 2010). Fibromyalgia + The Type “A” Personality = Chaos, Frustration, and Near Insanity! [Web log comment]. Retrieved from http://www.blogher.com/fibromyalgia-type-personality-chaos-frustration-and-near-insanity?page=full

“I Have Diabetes”

This episode revolves around three young adults coping with diabetes, coming to terms with their diagnosis and limitations, navigating the social realm with their disability, and facing difficulty in adopting the disciplined lifestyle required. The characters include Kristyn, a woman in her mid-twenties with $12,000 in debt working eighty hours a week to pay off medical expenses, who is forced to resume living with her parents. Next, Jen is a nineteen year old struggling to modify her eating habits and facing pregnancy complications due to diabetes. Matthew is a twenty year old student who does not want his condition to interfere with his college partying experience.

The illness narrative of the characters resembles the Chaos motif, since diabetes is a chronic affliction posing degenerative and life-threatening consequences with failure to administer insulin and stabilize glucose. Helplessness and a sense of spiraling out of control are prominent themes in this episode. For instance, after working multiple shifts, Kristyn breaks down crying and confides in her friend about feelings of social isolation. Along the same lines, after her newborn is put in the neonatal intensive care unit, Jen cries to her husband that “It’s not fair…I feel like this is all my fault, and there’s nothing I can do about it,” illustrating her sense of desperation and guilt. These examples also highlight other features of the Chaos Narrative, including hopelessness surrounding potential for a normal life, being overwhelmed by the intensity of the illness, and intimate relationships being the witnesses to the patient’s testimony.

The narrative is used by characters in order to explain decisions or justify health-compromising behavior to self, family, friend networks, and health care personnel, to mobilize sympathy and emotional support, to legitimize their sick role, or to involve others in their treatment selection or therapeutic course.  For example, Kristyn uses narrative in talking to her mother in order to rationalize her decision to go to the bar despite being sleep deprived, while Matthew prepares roommates for what they should do in a diabetic emergency.

Adoption of the sick role and revealing of their illness narrative is stigmatizing for the characters, as their condition precludes them from engaging in culturally-prescribed behavior for individuals of their age group. For example, Kristyn is socially alienated since her medical bills have forced her to forgo independent residency and work two full-time jobs. Jen has difficulty being estranged from our culture of fast-food consumerism, and feels excluded when she cannot indulge in sugary foods at the buffet like her mother.  Matthew feels pressured by friends at his birthday party when he cannot conform to social norms for imbibing alcohol.

This episode also portrays how the experience with medical professionals represents a transactional exchange between patient and practitioner, where they negotiate modification in treatment employed and articulate the extent of ‘the sick role’ of the patient. This underscores the superior position in the social hierarchy occupied by the doctor, who is the gatekeeper to treatment modalities and has power to impose diagnostic labels and exert control over patient behavior. For instance, Jen’s doctor had her switch from oral medication to injections despite her objections, and her physician changed her diagnosis from Type II to the more restrictive, irreversible Type I. In addition, Matthew felt as though he had to convince his doctor that he could manage his condition and consume alcohol, and resisted the sick role the biomedical community had assigned, not wanting to compromise his partying.  Moreover, the characters forgo certain rights in assuming the sick role, such as Jen’s right to deliver the baby when and how she wanted, and Matthew’s right to drink without inhibitions (instead, he has to take glucose readings at parties and carry Mountain Dew in case of hypoglycemia).  Sick role responsibilities portrayed include managing the financial burden of illness in Kristyn’s case, and complying with a dietician’s orders in Jen’s case.

The illness narrative is useful to patients in documenting their illness journey, deriving meaning from illness, and re-capturing a sense of agency. Importantly, the narrative can be a tool of catharsis and introspection, enabling the patient to self-reflect on their decisions and reactions and to find self-actualization through the transformative aspects of illness. In particular, the lecture underscored how the Restitution Narrative provides hope for cure by emphasizing the impermanent nature of illness, the Chaos Narrative provides acceptance and resignation, and the Quest Narrative provides self-empowerment and enlightens an individual about a positive metamorphosis in identity that can occur as a result of illness.  On the other hand, the illness narrative is useful to family because it offers a coherent scheme of events for the purpose of clarity and provides insight into the experiential facets of illness, such as the patient’s battery of emotions. For health care providers, the illness narrative can communicate subjective feelings of pain and distress and showcases a logical timeline of symptom expression and remedies pursued, which may illuminate etiology or better avenues for treatment.

As lecture stated, benefits for listeners with similar conditions include finding a sense of community and advice for recovering autonomy and living an enriching life with the illness. For example, Craig Mullins found solidarity with other men who had paternal postpartum depression, raised awareness about the disease, and identified afflicted men by releasing his illness narrative. Moreover, he was able to find redeeming aspects of confessing his illness experience, as demonstrated with: “Recognizing that what you’re experiencing is real and then seeking help…demonstrates strength and courage” (Stone, 2012). Likewise, on his YouTube video, Jeremy divulges that he posted his YouTube video illness narrative “in an effort to connect with other people out there who understand” (Jeremy, 2011). Hence, his illness narrative serves to initiate friendships with others with bipolar disorder, to share coping strategies, and to create a social identity through their shared suffering.

References

Jeremy. (January 30, 2011). My Story [Video File]. Retrieved from http://www.youtube.com/watch?v=dHS0rvizbJo&feature=related

Stone, K. (April 24, 2012). Depression in Men: A Dad’s Story of Male Postpartum Depression. Postpartum Progress: Together, Stronger. Retrieved from http://postpartumprogress.com/depression-in-men-a-dads-story-of-male-postpartum-depression

 

Amok in indigenous island and modern industrialized societies

“Running amok” refers to a mentally perturbed individual that engages in unprovoked, homicidal and subsequently suicidal behavior, oftentimes involving an average of ten victims. Formerly considered a rare psychiatric culture-bound syndrome, Saint Martin believes that “amok” is also prevalent in contemporary industrialized societies. Although it was not classified as a psychological condition until 1849, it was first described anthropologically two hundred years ago in isolated, tribal island populations such as Malaysia, Papua New Guinea, Puerto Rico, the Philippines, and Laos, where geographic seclusion and indigenous spirituality were cultural factors implicated in this CBS. For instance, spirit possession by the “hantu belian” or evil tiger spirit of Malay mythology was believed to be the source of the involuntary, indiscriminate violence that characterizes amok. Individual dimensions such as grief, acute loss, and interpersonal stress were also thought to contribute; for instance, an 1846 Malay incident was caused by an elderly man’s bereavement of his wife and child, while the offender in a 1998 Los Angeles incident suffered financial bankruptcy. Furthermore, individual variables, such as predisposition to aggression, and individuals with recurring cognitive themes such as persecution and revenge are instigating elements. Initial narratives by amok witnesses differentiated two forms that reiterate individual causative factors: “The more common form, beramok, was associated with a personal loss and preceded by a period of depressed mood and brooding; while the infrequent form, amok, was associated with rage, a perceived insult, or vendetta preceding the attack” (Saint Martin 2009).  In native cultures, sacred healers of the folk sector operated under cultural ideology where illness was believed to be of supernatural origin, so amok was tolerated and/or offenders were brought to trial.

As Western expansion encroached on remote cultures, incidence of amok decreased, reinforcing the view that culture was responsible for its pathogenesis. The author postulates that the escalating frequency of mass homicides in industrial cultures in the past quarter century represents amok, citing that attackers often have a history of mental disturbance and that modern episodes involve the same number of victims. Hence, biological dimensions of this illness include psychosis, personality disorders, and delusional disorders (in amok), and depressive or mood disorders (in beramok), as these maladies possess genetic elements. Also, dissociative disorder is suggested in instances where the assailant’s attack ends in exhaustion and amnesia for the event. Historically, this disorder has not been treated in the professional sector of Western biomedicine either; rather, perpetrators were apprehended and enter the criminal justice system or die by their own volition.

The author disputes classification of amok as a CBS since it seems to appear cross-culturally, and argues instead that culture is the mediating mechanism that determines how the violence manifests. For example, Jin-Inn Teoh claimed that amok appeared universally but that its mode of expression in terms of weapons and methods was culture-specific. Furthermore, John Cooper posited that its affiliation with suicide, a practice transcending cultures, disproves the classification of amok as a CBS. In essence, the author contends that amok is a product of mental illness, which has the same etiology and psychosocial precipitants worldwide. He advocates prevention by identification of individuals with risk factors and treatment of underlying psychological conditions. In addition to coworker, neighbor, friend, and family observations of susceptible individuals, Saint Martin states that physicians are uniquely positioned to collect data regarding those vulnerable to amok, since, “Many of these patients preferentially consult general and family practitioners instead of psychiatrists owing to the perceived stigma attached to consulting a psychiatrist, denial of their mental illness, or fear of validating their suspicion that they have a mental disorder” (Saint Martin 1999). Under the professional sector model, these individuals should be involuntarily committed if feasible, submitted for psychological evaluation, treated with drugs suitable for the diagnosed condition, and undergo psychotherapy. This is consistent with the biomedical paradigm, which is reductionist in focus, assigns irreversible diagnostic labels, imbues practitioners with enhanced credibility, and entitles practitioners to legally sanctioned authority such as mandating hospitalization of patients and controlling modality of treatment. Uncharacteristically, however, Saint Martin also recommends mobilizing the patient’s social support network, which is a holistic approach more aligned with folk sectors of medicine.

References

Cooper, J. (1934). Mental disease situations in certain cultures: a new field for research. Journal of Abnormal Sociology and Psychology, 29: 10–17.

Saint Martin, M.L. (1999) “Running Amok: A Modern Perspective on a Culture-Bound Syndrome”. Primary Care Companion to the Journal of Clinical Psychiatry, 1(3): 66-70. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC181064/?tool=pmcentrez

Teoh, J-I. (1972). “The changing psychopathology of amok”.  Psychiatry, 35: 345–351

Clown Doctors in New York City

1) This article proposes the similarity between a unit of professional clowns and shamans, both healers congruent with the folk sector of alternative medical systems. The clowns work in pediatric wards of New York City hospitals, where they interject “joy and mayhem” into the lives of patients, their families, and medical staff via performances of “funny-bone removals, squeakectomies, and bed-pandemonium” (page 462-463). The author argues that adoption of an additive, integrationist model of disease with collaboration between biomedical and complementary practitioners (like clowns) would facilitate better health outcomes.

2) Like shamans, the clown healers are “liminal figures” and “metacultural texts”, reversing and distorting cultural conventions, in the latter case to invoke hilarity, ameliorate pain with mental distraction, or provoke transference or catharsis through humorous devices such as satire and irony. Thus, their technique is production of emotional release by violating or inverting cultural rules. The healers assume clown doctor characters and use mime, farce, physical comedy, children’s theater, magic tricks, ventriloquism, and gags to produce psychological healing for patients and families.

They tailor their performances to the target audience age and affliction and supplement traditional biomedical care without being intrusive; they do not intervene while examinations are in progress, avoid quarantined zones, and employ sterile measures. Their social ranking is inferior to biomedical practitioners, as they must heed restrictions imposed by biomedical practitioners. Their skits are also aimed at patient empowerment, equalizing the doctor-patient power dynamic by parodying physicians and hospital procedures.

Furthermore, both shamans and clowns are viewed ambivalently, enter altered states of consciousness, and use music and rhythm to evoke a different reality. Importantly, they both entail a mystical element to which children are susceptible. For instance, with slight-of-hand, the clowns employ “symbolic healing” via manipulation of culturally-embedded symbols to “promote psychosomatic transformation,” by “enlisting the power of suggestion or placebo effect” (page 464, 469). They also mobilize psychosocial support, reduce family tension, and boost institutional morale by engaging all parties.

3) Although the clowns belong to the folk sector in their resemblance to shamans, they operate within the professional sector of health care. While practitioners in the folk sector share the cultural values of the society and view the body holistically (treating the psychological, spiritual and social realms and the subjective, experiential aspects of illness), the professional sector under which Western biomedicine falls delivers bioreductionist allopathic care geared toward clinical symptoms of disease entities based on a scientific, authoritative knowledge scheme. This latter sector predominates in developed and industrialized societies where the body is viewed through the lens of Cartesian dualism. Whereas practitioners in the professional sector are legally sanctioned and enjoy elite status and reputation, the clowns and other folk healers of traditional, non-Western societies are inferior on the social hierarchy and possess less prestige. The professional sector utilizes specific, compartmentalized approaches to somatic complaints, while the clowns and folk healers treat “the whole person, the social milieu, and the mental predicates of illness” (page 471).

Parkinson’s Disease among Hispanics and Whites

TABLE 1. Parkinson’s disease cases and population by gender, age, race/ethnicity, and year, Kaiser Permanente, 1994–1995

* Person-years by race/ethnicity are for age 30 years or older.

  Total Total person-years
Overall 588 4,776,038
Gender (all ages)

Female

male

 

 

230

358

 

2,461,498

2,314,540

Age (years)

30–39

40–49

50-59

60-69

70-79

>80

 

4

20

55

154

259

96

 

793,460

810,224

560,856

397,230

241,623

80,667

Race/ethnicity*

Non-Hispanic White

Black

Asian

Hispanic/Latino

Other

 

474

28

35

47

4

 

2,008,081

229,089

324,475

299,343

23,070

According to the Willis et al. study from 2010 (and illustrated from the table above, reproduced from the Eeden et al. study of 2003), the neurodegenerative condition Parkinson’s disease afflicts a disproportionate number of Caucasians and Hispanics as compared to African Americans and Asians. In the Willis study in particular, whites and Hispanics developed Parkinson’s at twice the rate of blacks and Asians. Genetic variables are predicted to explain only a small fraction of the variance between groups; rather, Willis speculated that that, “Environmental factors are likely more common contributors and may include prolonged exposures to herbicides and insecticides used in farming or to metals such as copper, manganese and lead” (News Medical). Another proposed reason for the difference was presence of a gene in those of Asian or African ancestry that confers protection from the disease.

Instead of a tangible, objective biological category, race is a social construct used to justify social hierarchies and oppression, discrimination, and persecution of certain groups and the privilege afforded to others. As cited in Taz’s lecture, genetic determinism is the notion that genetic endowment dictates our temperaments, behavior, intelligence, and health; in other words, the arbitrary demarcations between ‘races’ are used as a proxy for genetics such that overarching assumptions about health and disease predispositions are inferred. This theory is used to equate biological race and genetic similarities. For instance, BiDil designed and marketed its product for hypertension based on racial bifurcations based on health disparities between ‘races’, although such inequalities in heart disease are most likely owed to extraneous variables such as SES, prejudice, differential access to healthy food, less health insurance, etc. In reality, a constellation of factors including social, cultural, behavioral, psychological, and physiological parameters determine health outcomes, though Western medicine tends to favor biological explanations for divergent health over cultural or environmental ones.

References

News Medical. Editor. 2010. 13 July 2012 < http://www.news-medical.net/news/20100128 /Epidemiological-study-shows-Parkinsons-disease-is-more-common-among-whites-and-Hispanics.aspx>.

Van Den Eeden, S.K., Tanner, C.M, Bernstein, A.L, Fross, R.D., Leimpeter, A., Block, D.A., & Nelson, L.M. (2003). “Incidence of Parkinson’s Disease: Variation by Age, Gender, and Race/Ethnicity”. American Journal of Epidemiology, 157(11): 1015-1022.

Willis, A.W., Evanoff, B.A., Lian, M., Criswell, S.R., & Racette, B.A. (2010). “Geographic and Ethnic Variation in Parkinson Disease: A Population-Based Study of US Medicare Beneficiaries”. Neuroepidemiology, 34: 143-151.

 

“Becoming American”

  • I scored 6/10 on the Health Equity Quiz. One of the statistics I found most unexpected was that the greatest difference in life expectancy observed between U.S. counties was 15 years, and that these differences are intensified when comparing subgroups. Intuitively, I would think that variables such as health insurance, heredity, social support, and psychological resiliency would be the primary predictors of health. However, upon further evaluation, zip code is correlated with income, access to healthy and affordable options, safety and sanitation infrastructure, exposure to stressors, coping resources, job security, and crime rate, which in turn affect life expectancy.  In particular, it is disturbing that position on the class pyramid is the most potent indicator of health, as evidenced by a health-wealth gradient.  I was also astonished that chronic illness costs the U.S. $1.1 trillion in lost work productivity; given this economic burden, it is surprising that more people do not endorse state-sponsored health care, due to its potential to enhance preventative medicine measures and preempt chronic illness (only 48% of registered voters supported ‘Obamacare’ in a July 1 Reuters/Ipsos poll, according to the Huffington Post).
  • Unnatural Causes 3, “Becoming American,” addressed the Latino Health Paradox, the phenomena that new Mexican immigrants to the United States possess better health (in terms of lower rates of obesity, heart disease, diabetes, etc.) than their native-born American counterparts, including those of higher socioeconomic status and education. The longer immigrants live in the United States, the more they adopt an Americanized lifestyle (poor diet, sedentary activity levels, occupational stress), are exposed to discrimination, and their health begins to resemble other Americans. The buffering effects of being a new immigrant are attributed to cultural variables such as family cohesiveness, social support, and affiliation with cultural identity, which are eroded with longer duration in America and disappear in successive generations. The video suggests that providing opportunities for community involvement, decent housing, jobs, and wages, and retaining traditions of the culture of origin can extend the protective effects to health.
  • According to the ecological approach viewed through the lens of political ecology, at a macro-level of analysis, historical, economic, social, and political transformations of populations bear directly on disease origination, frequency, distribution, and dissemination. As McElroy cites, “fluctuations among, or disruption of biotic, abiotic, and cultural subsystems,” when exceeding human adaptive capacity, can lead to “environmental degradation, loss of resources, population decline, changes in trophic (feeding) relations, and disease”.  For instance, shistosomiasis development in North Africa in the 1950s and 1960s was a consequence of dam construction as part of Egyptian economic policy, which perturbed ecological niches and caused disease emergence. By the logic of cultural ecology, culturally entrenched beliefs and practices can disturb fragile human-pathogen equilibriums and hence create or spread disease. For example, a 1988 study by the Mulls examined how rural Pakistani mothers rejected oral rehydration therapy on the grounds that diarrhea was a ‘hot’ illness necessitating ‘cold’ treatment, a category under which Western did not fall according to their ethnomedical model.  Here, cultural beliefs and individual choice about employing a treatment modality precluded their use of ORT and perpetuated morality from diarrheal illnesses. Furthermore, biology can influence disease prevalence by adaptive mutations conferring selective advantage, as is the case with heterozygosity of Sickle Cell alleles which engenders malarial resistance.

References

Mull, J.D., & Mull, D.S. (1988) “Mothers’ concepts of childhood diarrhea in rural Pakistan:

what ORT program planners should know”. Social Science & Medicine, 27(1), 53-67.